Medicare Payer Program
Student’s Name
Institutional Affiliation
Part One
The Medicare program of 1965 was created to help finance the cost of healthcare for American citizens above the age of 65. The program thereby affects licensure, certification, and accreditation standards in healthcare. Licensure in healthcare is done annually, and without licensure, healthcare facilities cannot operate. State licensure dictates that hospitals and physicians must get licensed in the respective states of practice. Medicare affects licensure because it makes state licensure a requirement. Medicare also affects certification in that it the body responsible for certifying hospitals and physicians. The certification is done according to the scope of medicine that physicians and hospitals practice. For physicians to get certified, they must comply with the conditions of participation set by Medicare to be eligible. The accreditation process for hospitals is done by the Joint Commission or the American Osteopathic Association (AOA) (Leers, 2017). If hospitals are not accredited by these two bodies, they are not considered compliant with Medicare.
Medicare payer program influences quality reporting systems through the pay per performance incentives. The Centers for Medicaid and Medicare Services (CMS) is where Medicare gets its statistics on these reports. Medicare influenced the reporting systems by establishing the need for more comprehensive systems in reporting quality performance. Through the incorporation of Value Modifier and PQRS, CMS can get more informed reports on the quality of care. CMS is also responsible for setting the reimbursement rates for healthcare services and the equipment that they provide (Leers, 2017. Healthcare providers cannot ask Medicare patients to cover the difference between Medicare set fees and the normal rates they charge people who are not covered. Medicare affects access to care as it increases care for patients under the program. The program has allowed people who would be discriminated against due to their age and pre-existing condition to get insurance, thereby increasing healthcare access.
Part Two
Healthcare providers facilitate the role of care coordination in healthcare. Care coordination refers to the processes of organizing patient care activities and the interprofessional sharing of information among providers. The role is focused on increasing the quality of care, reflecting in the quality reporting systems of Medicare. Care coordination is crucial in increasing the quality of healthcare because it ensures that the needs and preferences of a patient are met (Witwer & Wallenstein, 2019). The information must be communicated on time and with the right people for the effectiveness of care. The information should also guide healthcare delivery.
Care coordination without proper communication of information can lead to numerous challenges. If a physician referred a patient to a specialist and there was poor communication on the needs of the patient, it would result in poor patient outcomes. It is also important that care coordination includes communication with the patient. When patients are referred to specialists without knowing why they were sent there, it reduces the level of patient involvement in healthcare decisions. Poor communication can also lead to increased healthcare costs. If physicians are not clear about the tests a patient has already had, specialists might redo these tests on the patient. It will lead to increased healthcare costs. Healthcare facilities need to have care coordination strategies and set goals for healthcare providers to meet. Increasing care coordination will reflect on increased healthcare quality which affects the reimbursement by Medicare. Care coordination will also reflect on the performance of Medicare physicians.
References
Leers, S. A. (2017). Improving Quality in Noninvasive Testing by Certification and Accreditation. In Noninvasive Vascular Diagnosis (pp. 3-14). Springer, Cham.
Witwer, S. G., & Wallenstein, D. W. (2019). Education and engagement of patients and families: the essential role of the care coordinator and transition manager RN. AAACN Viewpoint, 41(1), 1-13.